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Expanding buprenorphine in U.S. jails: One county's response to addressing the fears of diversion

Published:January 10, 2023DOI:https://doi.org/10.1016/j.josat.2022.208944

      Highlights

      • Buprenorphine is a highly efficacious form of treatment for OUD.
      • Fears of diversion cause buprenorphine to be underutilized in correctional facilities.
      • Facilities that expand buprenorphine have not found diversion to be a primary concern.
      • Lessons can be learned from these early adopting facilities.

      Abstract

      Introduction

      The overdose crisis continues to be a major public health emergency in the United States. While effective medications for opioid use disorder (MOUD), such as buprenorphine, have ample scientific evidence to their effectiveness, they are underutilized in the United States and particularly in criminal justice settings. One rationale against the expansion of MOUD in carceral settings cited by jail, prison, and even Drug Enforcement Administration leaders is the potential for diversion of these medications. However, currently little data exist to support this claim. Instead, successful examples from early expansion states could help to change attitudes and calm misconceptions around diversion fears.

      Results

      In this commentary, we discuss the experience of one county jail that successfully expanded buprenorphine treatment and did not suffer significant impacts related to diversion. Instead, the jail found that their holistic and compassionate approach to buprenorphine treatment improved conditions both for incarcerated individuals and jail staff.

      Conclusion

      Amid a changing policy landscape and a federal commitment to increase access to effective treatments in criminal justice settings, lessons can be learned from jails and prisons that have already or are working toward expansion of MOUD in their facilities. Ideally, these anecdotal examples, in addition to data, will help to encourage more facilities to incorporate buprenorphine into their opioid use disorder treatment strategies.

      Keywords

      1. Introduction

      Buprenorphine is a highly safe and efficacious medication that, along with methadone, is the gold standard treatment for opioid use disorder (OUD) (
      • National Academies of Sciences and Medicine, E.
      • Division H.a.M.
      • Policy Disorder, B.o.H.S.
      • Mancher M.
      • Leshner A.I.
      Committee on Medication-Assisted Treatment for Opioid Use
      Medications for opioid use disorder save lives.
      ). Although buprenorphine has been proven to significantly improve a variety of health outcomes, including reduced risk of illicit opioid use, increased treatment retention, reduced HIV-risk behaviors, reduced overdose death, and improved quality of life, it remains highly underutilized in the United States (
      • National Academies of Sciences and Medicine, E.
      • Division H.a.M.
      • Policy Disorder, B.o.H.S.
      • Mancher M.
      • Leshner A.I.
      Committee on Medication-Assisted Treatment for Opioid Use
      Medications for opioid use disorder save lives.
      ). Buprenorphine is especially lacking within the criminal legal system, despite high rates of substance use disorders and overdose risk among people who are incarcerated (
      • National Academies of Sciences and Medicine, E.
      • Division H.a.M.
      • Policy Disorder, B.o.H.S.
      • Mancher M.
      • Leshner A.I.
      Committee on Medication-Assisted Treatment for Opioid Use
      Medications for opioid use disorder save lives.
      ). Expanding buprenorphine access in jails and prisons is often met with hesitation due to misconceptions about this medication and particular fears of medication diversion (
      • Doernberg M.
      • Krawczyk N.
      • Agus D.
      • Fingerhood M.I.
      Demystifying buprenorphine misuse: Has fear of diversion gotten in the way of addressing the opioid crisis?.
      ). However, experiences from early adopting jails and prison systems show that expanding comprehensive access to buprenorphine in carceral settings is a feasible and safe method to address the need for OUD treatment among justice-involved populations.

      2. Why buprenorphine?

      As a partial opioid agonist, buprenorphine relieves many of the negative symptoms associated with opioid withdrawal and cravings that can contribute to repeated drug use. Due to the way buprenorphine is regulated, it is also much easier to implement in carceral settings compared to methadone, which requires more complex licensing to administer. Evaluations of programs that have implemented buprenorphine and other medications for opioid use disorder (MOUD) in carceral settings have successfully decrease overdose mortality risk (
      • Moore K.E.
      • Oberleitner L.
      • KMZ S.
      • Maurer K.
      • SA M.K.
      Feasibility and Effectiveness of Continuing Methadone Maintenance Treatment During Incarceration Compared With Forced Withdrawal.
      ) and increased treatment retention postrelease (
      • Gordon M.S.
      • Kinlock T.W.
      • Schwartz R.P.
      • O’Grady K.E.
      • Fitzgerald T.T.
      • Vocci F.J.
      A randomized clinical trial of buprenorphine for prisoners: Findings at 12-months post-release.
      ). Additionally, using MOUD in carceral settings has also been found to reduce the risk of suicide (
      • Larney S.
      • Gisev N.
      • Farrell M.
      • Dobbins T.
      • Burns L.
      • Gibson A.
      • Kimber J.
      • Degenhardt L.
      Opioid substitution therapy as a strategy to reduce deaths in prison: Retrospective cohort study.
      ), increase effective participation in court proceedings (
      • Fendrich M.
      • LeBel T.P.
      Implementing access to medication assisted treatment in a drug treatment court: Correlates, consequences, and obstacles.
      ), decrease disciplinary infractions (
      • Moore K.E.
      • Oberleitner L.
      • KMZ S.
      • Maurer K.
      • SA M.K.
      Feasibility and Effectiveness of Continuing Methadone Maintenance Treatment During Incarceration Compared With Forced Withdrawal.
      ), and reduce recidivism (
      • Evans E.A.
      • Wilson D.
      • Friedmann P.D.
      Recidivism and mortality after in-jail buprenorphine treatment for opioid use disorder.
      ). And yet most people involved in the criminal legal system are likely to suffer from inadequate access to MOUD: only 13 % of correctional facilities offer any MOUD (
      Calculated from Jail and prison opioid project (JPOP) on 7/30/21.
      ), and of those referred by the criminal legal system to treatment in the community, less than 5 % access any type of MOUD (
      • Krawczyk N.
      • Picher C.E.
      • Feder K.A.
      • Saloner B.
      Only one in twenty justice-referred adults in specialty treatment for opioid use receive methadone or buprenorphine.
      ).

      3. Diversion concerns remain a deterrent in offering treatment

      Multiple factors make it challenging to implement all MOUD and buprenorphine, specifically, in jails and prisons. Among these are limited resources and highly regulated operations; the logistics of short-term stays, especially in jail settings; and concerns regarding limited MOUD resources for continued care in the community upon release (
      • Bandara S.
      • Kennedy-Hendricks A.
      • Merritt S.
      • Barry C.L.
      • Saloner B.
      Methadone and buprenorphine treatment in United States jails and prisons: Lessons from early adopters.
      ). However, at the center of this challenge remains a stigma toward substance use disorders and a rigid concern for the misuse, illicit use, or diversion of buprenorphine among individuals who are incarcerated. While jail administrators widely accept the use of medication prescribed for other mental health disorders despite diversion, the benefits of MOUD for substance use disorder are often trumped by fear and stigma and result in stringent policies that restrict buprenorphine initiation and use in criminal justice settings.
      These concerns persist despite little evidence on the legitimate disruption caused by buprenorphine diversion in criminal legal settings. While some individuals report use of nonprescribed buprenorphine for recreational purposes (
      • Gryczynski J.
      • Lee J.D.
      • Dusek K.
      • McDonald R.
      • Sharma A.
      • Malone M.
      • Monico L.B.
      • Cheng A.
      • DeVeaugh-Geiss A.
      • Chilcoat H.D.
      Use of non-prescribed buprenorphine in the criminal justice system: Perspectives of individuals recently released from incarceration.
      ;
      • Monico L.B.
      • Gryczynski J.
      • Lee J.D.
      • Dusek K.
      • McDonald R.
      • Malone M.
      • Sharma A.
      • Cheng A.
      • DeVeaugh-Geiss A.
      • Chilcoat H.
      Exploring nonprescribed use of buprenorphine in the criminal justice system through qualitative interviews among individuals recently released from incarceration.
      ), as a partial agonist, buprenorphine has a ceiling effect, which makes it much safer and less prone to experiencing the intense euphoric effect or overdose risk as with full agonists such as heroin or oxycodone. Evidence of buprenorphine use, even when accessed from diverted sources, shows that individuals benefit significantly from any access to buprenorphine, with a higher frequency of nonprescribed buprenorphine use associated with a lower risk of overdose, and increased interest in using prescribed buprenorphine (if available) and initiating buprenorphine treatment (
      • Cicero T.J.
      • Ellis M.S.
      • Chilcoat H.D.
      Understanding the use of diverted buprenorphine.
      ).

      4. Lessons from an early adopter of jail-based buprenorphine

      Despite a plethora of research on motivations for diverted buprenorphine, we still lack concrete examples and empirical research on the effects of improving access to medically prescribed buprenorphine on safety and diversion in jails and prisons. But as jails and prisons begin to lean toward the adoption of expanded MOUD practices, we can learn from the experiences of early adopters. Since February 2019, one jail located in Camden, New Jersey, for which one of the authors (KT) serves as the jail Warden, has made buprenorphine initiation and maintenance available to any individual with an OUD.
      When developing internal policies and practices, this jail approached their MOUD prescribing with a medical and harm reduction lens. All staff hired to become correctional officers receive education on OUD and training on MOUD at the academy. Those who come to work at Camden jails are given additional training on the OUD program led by partnering addiction experts at Rutgers University. Both trainings take a public health approach to OUD, teaching officers about the biological impacts of opioid use and its impact on behavior, and how MOUD and other strategies taken by the jail (like distribution of Narcan and fentanyl test strips) can help to reduce harms when individuals re-enter the community. To increase staff buy-in, officers receive continued education that is integrated into existing meeting infrastructure. Following these trainings, leadership has found that staff better understand OUD and treatment options and are less resistant and more committed to supporting effective treatment with MOUD. Staff have also reported feeling like they are supporting individuals with OUD and helping them safely return to the community.
      Camden, which is operating under New Jersey's bail reform efforts, has a large number of individuals with OUD rotate quickly through the system, with many staying for fewer than 48 h. Historically, individuals entering with an OUD would undergo drug detoxification before being released back into the community. With growing evidence that detoxification protocols contribute to increased risk of loss of tolerance and subsequent overdose upon release from incarceration, the Camden County jail implemented a unique screening protocol aiming to increase access to more effective and humane treatment by offering all individuals evidence-based treatment with MOUD. Upon admission, all individuals receive an immediate medical evaluation for OUD and MOUD are offered to individuals with OUD. Therefore, even individuals who will leave within 24 h can receive treatment. Re-entry staff, or MOUD navigators, also provide access to a parting dose and connection to community treatment.
      Following the implementation of the MOUD program at Camden jail, leadership and staff buy-in has increased, and they report improvements in the general environment within the jail. They have seen the general health of individuals improve, the number of acute psychiatric interventions decline, and concerns about diversion decrease. Although diversion incidents exist, this jail utilizes educational approaches rather than punitive measures or treatment discharge, which could result in increased overdose risk. Jail staff treat buprenorphine diversion as they would any other medication diversion, by finding ways to understand the reasons for and mitigate the diversion to help re-stabilize patients on the medication.
      Over time, diversion protocols have been adjusted as staff continue to learn how to best meet the needs of incarcerated individuals. When a diversion incident occurs, the current policy is for officers to report the diversion and notify the medical provider. Providers then discuss the incident and provide re-education to OUD patients and refer them for additional counseling. The team works cooperatively to identify the underlying reason for the diversion, which could include incidents such as receiving more medication than needed or being pressured by another individual to give up their medication. The team will work with the individual to find the proper dose or to address relationship dynamics that may contribute to diversion. If diversion incidents continue, patients may be given options to adjust dosing or route of administrations that may make diversion more difficult (e.g., switching from sublingual to injectable buprenorphine). Staff prioritize a person-centered approach to treatment and provide multiple options to the individual in hopes of maintaining treatment rather than opting for program dismissal.

      5. Moving toward an evidence-based approach to OUD in criminal legal settings

      Ultimately, data strongly support that buprenorphine can improve health and save lives. As argued by many, all forms of MOUD, including buprenorphine, should therefore be made available to all people with OUD in criminal legal settings interested in receiving such treatment. While we wait on empirical research to assess the long-term impacts of buprenorphine treatment availability on diversion and other carceral environment outcomes (findings from a study on overdose outcomes pre- and post-MOUD expansion in Camden is coming soon), lessons from the experiences of early adopters such as Camden tell us that diversion is merely a testament to the need for more accessible treatment options for individuals with OUD. Expanding access to MOUD while using reasonable and informed approaches to understand root causes and solutions for diversion across settings will help us to mitigate long-term harm, particularly in a landscape of increasing drug potency and overdose risk. We must continue to learn from successful models and invest in studying the long-term changes brought on by a health-focused approach to addressing substance use problems among people who encounter the criminal legal system.

      Declaration of competing interest

      We have no conflicts of interest.

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